Several workshop speakers and forum members highlighted the multidimensional needs of children across the areas of social protection, health, nutrition, and education and how natural linkages across these areas support children’s health, growth, and development as long as the efforts are culturally responsive, grounded in the research, and coordinated. In addition, multiple workshop speakers highlighted the nature of two generational approaches and investing in the caregiver to best leverage that relationship to fully support child development.
Investments That Are Grounded in the Research, Culturally Responsive, and Coordinated to Maximize Results
Children require integrated support and coordinated investments. The science linking brain development, psychology, nutrition, and growth affirms that policies and programs that support the development of young children should be evidence-based and multidisciplinary rather than fragmented across siloes that sever children’s needs into separate, uncoordinated services (Huebner et al., 2016). By focusing on only a single element of the burden of risks, the effect on outcomes is diminished. Coordinated, multifaceted, and evidence-based action can help ensure that young children benefit fully from policies and services and achieve better outcomes over the long term. For example, Bundy suggested that policy makers should consider health and nutrition when implementing improvements to education because interventions in health and nutrition have the same level of impact on access to schooling as educational interventions (IOM and NRC, 2014). From his perspective, school meal programs should not be considered solely as a nutrition intervention, but as an educational intervention as well because they are designed as a social safety net and support for education.
Frealem Shibabaw from the Ethiopian School Meal Initiative (ESMI) also believes education cannot be separated from nutrition and health (NASEM, 2016d). In Ethiopia, where 40 percent of children are stunted, the government of Ethiopia was not financially equipped to feed all of its school-aged children, so she founded the ESMI. Stunting is used as a measure of nutritional status and serves as an indicator for chronic undernutrition (WHO, 1997). The ESMI model provides 10 cows to each participating school. Half of the daily milk produced is consumed by the school children, and the other half is sold to the surrounding community to cover the administrative costs of running the program. Shibabaw reported that she saw results of ESMI immediately. School enrollment and attendance increased, the school community learned more about the importance of nutrition, and the ministry of education became more aware of the effect of nutrition on education (NASEM, 2016d).
Investments in Caregivers and Their Ability to Provide Care Promote Child Development
The forum discussed areas of investment in maternal health and nutrition. Maternal nutrition directly supports infant and child health and nutrition, especially during the prenatal and lactation periods. For example, as discussed in the forum’s initial workshop, poor maternal health and nutrition before, during, and after pregnancy, as well as inadequate feeding practices during the 1,000 days from conception through a child’s second birthday, lead to stunting. High rates of stunting and poor nutritional status represent a significant loss of child developmental potential, stated Ramanan Laxminarayan from the Center for Disease Dynamics, Economics & Policy (IOM and NRC, 2014). To illustrate this point, he showed results that indicate that height is correlated to positive outcomes such as improved cognitive scores and health, greater educational attainment, and higher wages (Vogl, 2014). In addition to the role of caregivers in children’s health and nutritional status, some workshop speakers pointed out the importance of positive interactions between caregivers and young children to support their social and emotional development (IOM and NRC, 2014; NASEM, 2016d).
Children need access to adult time and quality care. According to Abubakar (IOM and NRC, 2014), quality of care is compromised when a caregiver is suffering physically, mentally, or economically and is associated with negative outcomes in a child’s growth and development. Atif Rahman from the University of Liverpool emphasized that depression is a common mental health issue experienced by mothers (IOM and NRC, 2014). Thus, investments in the mental health of mothers may be particularly effective as the responsive interactions between mother and child are building foundational schemas that shape how children interact with others (Parsons et al., 2012). By improving the health and well-being of caregivers, said Abubakar (IOM and NRC, 2014), stakeholders can promote the development potential of children.
Rahman dispelled the myth that maternal depression has no effect on children. On the contrary, he explained that strong evidence links maternal depression to less adequate prenatal care, reduced breastfeeding, child undernutrition, child diarrhea, less adequate health care, and increased family stress, among other negative outcomes (Rahman, 2013; Rahman et al., 2008, 2013a,b; Wachs and Rahman, 2012). He cited further evidence that interventions by nonspecialists can be delivered to improve maternal psychosocial well-being (Rahman et al., 2013b) and argued that strategies to combat maternal depression can and should be integrated with maternal and child health programs (IOM and NRC, 2014).
Another approach to investing in caregivers to support child health and well-being is home visiting by trained personnel. Claire Runciman of the Australian Nurse–Family Partnership Program (NASEM, 2015) presented the Australian Nurse–Family Partnership Program as an example of a targeted program that consists of home visits by nurses to women who are pregnant with an Aboriginal or islander child, over the course of 30 months (Stavrakos et al., 2009). The program is run out of community-controlled Aboriginal health service organizations, which are trusted by and have very strong links with the community. Because there are not many aboriginal nurses, the nurses are introduced to clients by family partnership workers to ensure that the relationship is strong. The nurses are also given training in micro-communication and are given guidelines for conducting home visits, which they can adapt to their clients’ unique situation.
This adaptation to local circumstances and constant innovation is integral to its success and scalability (Hill and Olds, 2013).
Highlighting situations of compounded risk, Abubakar (IOM and NRC, 2014) noted that caregivers with human immunodeficiency virus (HIV), when ill, miss work, have more extensive medical expenses, and are often taken care of by the very children they are meant to be providing care for, leading to possible increases in caregiver mental health issues, including depression and anxiety. Abubakar called for the root causes of these problems to be addressed. At the same time, to combat these adverse circumstances, Abubakar encouraged the use of psychosocial stimulation to enhance the potential of caregivers (Potterton et al., 2010). She echoed Rahman, adding that community health workers can be very helpful in reaching parents.
Jody Heymann from the University of California, Los Angeles, highlighted that paid parental leave is essential if parents are to have the time and financial resources to care for infants (NASEM, 2016d). According to studies she cited, 185 countries around the world have paid maternity leave, while only half of these countries offer paid paternity leave, and only a quarter of which offer 3 weeks or more. Given that paid paternity leave is associated with a father’s increased involvement with their children for years after the leave, lower rates of maternal depression, and better child outcomes, Heymann emphasized the need for the same global agreement about paternity leave as there is for maternity leave (Heymann et al., 2013a). Heymann further advocated for breastfeeding breaks at work citing the evidence that breastfeeding lowers infant mortality and is a powerful early childhood intervention that promotes child health and well-being (Heymann et al., 2013b; NASEM, 2016d).
Investments in Early Education
According to Claudia Costin of the World Bank, too few children benefit from early childhood programs because policy makers do not always realize the importance of this investment and parents are sometimes unaware of the benefits (IOM and NRC, 2015b). She described an effort in Brazil to ensure that every child is enrolled in a program, but noted that full enrollment is not enough. Programs should be of high quality because studies indicate that enrollment in poor-quality programs can be detrimental to development, she said. Despite studies showing the benefits of early childhood programs, Bundy found that the number of teachers and trained caregivers remains very small relative to the number of adolescent girls and mothers caring for young children (IOM and NRC, 2014). Along with interactions with responsive adults in safe environments, children should be given opportunities to play and learn. It is therefore important that families, communities, and governments invest in promoting equitable access to quality preprimary education, prioritizing children with developmental delays and disabilities and children from marginalized groups (Huebner et al., 2016).
Many individual speakers noted that in order to promote access to quality programming for young children, capacity is required, and capacity within frontline, program, policy, education, training, and research contexts is often very limited in low- and middle-income countries (IOM and NRC, 2015b).
One approach to building capacity, as presented by Alan Pence of the University of Victoria, has been to highlight the importance of promoting leadership at multiple levels, organizations, and sectors within specific countries, and then providing an online educational environment that allows these leaders to learn and interact across countries in order to develop contextually effective ways forward (NASEM, 2017; Pence, 2013). This Early Childhood Development Virtual University approach has been augmented by a complementary African research scholars’ initiative (Marfo et al., 2011) to ensure that system development and capacity building is continually informed by the science (NASEM, 2017). It is important, according to Kofi Marfo of Aga Khan University, that the science is culturally grounded in the linguistic and cultural norms and customs of the population being served. Therefore, regional networks across Africa are needed to inform programming (NASEM, 2017).
One example of an investment in early childhood education that is grounded in cultural and linguistic contexts is mother tongue–based education in Vietnam (NASEM, 2015). According to Emma Pearson of the Universiti Brunei Darussalam, this program allows children in minority groups who have been struggling in mainstream education to use their mother tongue during the preschool years and for the first 3 years of primary school. The children transition to the mainstream curriculum in later school years. Given the positive results, the program has shown to be effective at the local level and informing national policy in Vietnam, said Pearson (NASEM, 2015).